April 02, 2014

Law Professors, Law Students and Depression . . . A Story of Coming Out (Part 2)

In Part I of this little series, I laid out some of the statistics regarding the scope of the problem of depression and anxiety among lawyers and law students. Before I tell my story, I want to spend a little time talking about why these diseases are so prevalent among lawyers.

One of the more eloquent “whys” for the high incidence of depression among lawyers was contained in an opinion piece by Patrick Krill (a lawyer, clinician and board-certified counselor) that accompanied the CNN article on lawyer suicides. As Patrick put it, “lawyers are both the guardians of your most precious liberties and the butts of your harshest jokes[; i]nhabiting the unique role of both hero and villain in our cultural imagination….” Patrick explained that the high incidence of depression (and substance abuse, which is another huge problem) was due to a number of factors but that “the rampant, multidimensional stress of the profession is certainly a factor.” Further, “there are also some personality traits common among lawyers — self-reliance, ambition, perfectionism and competitiveness -- that aren't always consistent with healthy coping skills and the type of emotional elasticity necessary to endure the unrelenting pressures and unexpected disappointments that a career in the law can bring.”

Patrick’s discussion of this issue really stuck a cord with me. Practicing law is hard. The law part is not that hard (that was the fun part for me), but the business side of law is a bear. Finding clients, billing time, and collecting money, are just a few aspects of the business of law of which I was not a big fan. Keeping tasks and deadlines in dozens (or hundreds) of cases straight and getting everything done well and on time is a constant challenge. The fear of letting one of those balls drop can be terrifying, especially for the type A perfectionist who is always terrified of making a mistake or doing a less than perfect job. Forget work-life balance. Forget vacations. Every day out of the office is another day you are behind.

Plus, as a lawyer (and especially as a litigator), no matter how good a job you do, sometimes you lose. That inevitable loss is made worse by the emotion that the lawyer often takes on from his or her client. Almost no client is excited to call her lawyer. Clients only call, of course, when they have problems. Those problems can range from the mild (for example, a traffic ticket) to the profound (like a capital murder charge). But whatever the problem, the client is counting on the lawyer to fix it. Every lawyer I know takes that expectation and responsibility very seriously. As much as you try not to get emotionally invested in your client’s case or problem, you often do. When that happens, losing hurts. Letting your client down hurts. This pain leads to reliving the case and thinking about all of the things you could have done better. This then leads to increased vigilance in the next case. While this is not necessarily a bad thing, for some lawyers this leads to a constant fear of making mistakes, then a constant spike of stress hormones that, eventually, wear the lawyer down. The impact of this constant bombardment of stress hormones can be to trigger a change in brain chemistry that, over time, leads to major depression.

Depression is a subtle and insidious disease. By the time you are sick enough to recognize that you have a problem, your ability to engage in accurate self-evaluation is significantly impaired. It is a strange thing to know, deep down, that something is wrong with you but to not be able to recognize the massive changes in yourself. Helping yourself at that point is often impossible. Unfortunately, those suffering from depression become expert actors who are extremely adept at hiding their problems and building a façade of normalcy. Eventually, it takes all of your energy to maintain this façade. The façade becomes the only thing there is.

Depression is not a character flaw. It is not a weakness. It is not a moral failing. You cannot “just get over it.” No amount of will-power, determination or intestinal fortitude will cure it. Depression is a disease caused (in very basic and general terms) by an imbalance and/or insufficiency of two neurotransmitters in the brain: serotonin and norepinephrine. In this way, it is biologically similar to diabetes, which is caused by the insufficiency of insulin in the body. As a disease, depression can be treated – and treated very effectively. But it takes time and it takes help – personal help and professional help.

And now we get to the personal part. Don’t say I didn’t warn you.

Though I likely had been depressed for a long while, I was diagnosed with severe clinical depression in late 2005. As another lawyer who helped me put it, suffering from depression is like being in the bottom of a dark hole with – as you perceive it from the bottom – no way out. The joy is sucked from everything. Quite often, you just want to end the suffering – not so much your own, but the perceived suffering of those around you. You have frequent thoughts that everyone would be better off if you were not around anymore, because, being in such misery yourself, you clearly bring only misery to those around you. When you are in the hole, suicide seems like the kindest think you can do for your family and friends, as ending your life would end their pain and misery.

While I do not remember all of the details of my decent into the hole, it was certainly rooted in trying to do it all – perfectly. After my second child was born, I was trying to be all things to all people at all times. Superstar lawyer. Superstar citizen. Superstar husband. Superstar father. Of course, this was impossible. The feeling that began to dominate my life was guilt. A constant, crushing guilt. Guilt that I was not in the office enough because I was spending too much time with my family. Guilt that I was letting my family down because I was spending too much time at work. Guilt that I was letting my bosses down because I was not being the perfect lawyer to which they had become accustomed. Guilt. Guilt. Guilt. The deeper I sunk into the hole, the more energy I put into maintaining my façade of super-ness and the less energy was left for either my family or my clients. And the guiltier I felt. It was a brutal downward spiral. Eventually, it took every ounce of energy I had to maintain the façade and go through the motions of the day. The façade was all there was. Suicide seemed rational.

There were danger signs, of course, but neither I nor anyone around me recognized them for what they were. I burst into tears during a meeting with my bosses. I started taking the long way to work in the morning and home in the evenings – often taking an hour or more to make the 5 mile trip. Eventually – after months of this – my wife asked me what was wrong and I responded, “I just don’t know if I can do this anymore.” She asked what “this” was. I said, “you know . . . life.” And started bawling. The façade crumbled and I was utterly adrift. [I don’t actually remember this conversation with my wife, but she does.]

After getting over the initial shock of my emotional collapse, my wife forced me to go to the doctor and get help. She took the initiative to find a doctor, make me an appointment and take me (which is good, because I was utterly incapable of doing any of those things). She called my firm and told them I needed FMLA leave. One of my colleagues put me in touch with the N.C. State Bar’s Lawyer Assistance Program, as well as with Louis Allen (the Federal Public Defender for the M.D.N.C.) who had suffered from severe depression and recovered. With Louis’s help, treatment from my doctor and the support and love of my family, I got better and better. I started taking medication and clawed my way to the top of the hole. But, for more than a year, I was sort of clinging to the edge of the hole about to plummet back down. So, I changed doctors and medications and did a lot of talk therapy. Eventually, more than 18 months later, I was finally back to some semblance of my “old self.” I was happy again (mostly). I was a good father again (mostly). I was a good husband again (mostly). I enjoyed being a lawyer again (mostly). I enjoyed life again.

There have been a couple of relapses, where the hole tried to reclaim me. However, I never fell all the way back down. I will happily take medication for the rest of my life. And I will regularly see a therapist for the rest of my life. I will be forever vigilant regarding my mental state. Small prices to pay.

Had I not gotten help, I would not be writing this post because I would likely not be alive today. No amount of will power or determination could have helped me climb out of that hole. Only by treating my disease with medication and therapy was I able to recover, control my illness and get my life back.

Now, I don’t write any of this to solicit sympathy or pity. I am doing fine. I have five wonderful (if occasionally maddening) children and an amazing wife. I have a job that I love and am truly good at. I have the job that I was put on this earth to perform, which makes me incredibly lucky. I have wonderful students who will be outstanding lawyers. I have no complaints.

I write this because I know that when you are depressed you feel incredibly, profoundly alone. You feel that you are the only person on earth who has felt the way you do. You feel like no one out there in the world understands what you are dealing with. You feel like you will never feel “normal” again.

But you are not alone. You are not the only person to feel this way. There are lots of people who understand. I understand. I have been there. I got better. So can you.

So, please, if you are suffering from depression or anxiety (or both) get help. Tell your spouse. Tell your partner. Tell a colleague. Ask for help. Asking for help does not make you weak. It takes profound strength to ask for help. You can get better. You can get your life back.

Trust me when I say that life is so much better once you get out of – and away from – that dark hole. It is well worth the effort.

[While I'd hoped that I did not need this disclaimer regarding comments, apparently I do: As this is a serious topic, I will moderate any comments to this post and delete anything I deem inappropriate or off topic.]

With all due regard and respect for your personal experience with depression, it's simply not true that all (indeed, if any) forms of depression are indicative of a "disease" in the biomedical sense as there is not, as yet, a satisfactory etiology of depression in biomedical language. Some forms of depression appear to indeed have physiological connections and are related to functions in the brain, but these are, at best, necessary yet not sufficient conditions (at least to date) of depression as a mental illness, severe or otherwise. More severe forms of depression are amenable in some measure to treatment with antidepressant drugs (in which case they treat symptoms but not causes) but this is not everywhere and always the case. Much of what goes under the heading of depression should not be classified as severe mental illness, and certainly not as a disease in the strict sense (much like alcoholism is not a 'disease' in the biomedical sense as explained by Herbert Fingarette, among others). Please see, for instance, the following works:

Greenberg, Gary. Manufacturing Depression: The Secret History of a Modern Disease (New York: Simon and Schuster, 2010).

I take synthroid every day to correct my body chemistry for an under active thyroid. I do not feel weak because I must rely on a drug to make it through the day. We should view people who take drugs to correct a body chemistry deficiency that results in psychiatric problems in the same light. Maybe society will grow up someday. I hope so.

Bill, I think you are absolutely correct that psychiatric problems should be viewed like other medical problems and not stigmatized. However, there is no medical evidence whatsoever that depression is "a body chemistry deficiency."

Please note that I am not a doctor and I am not trying to tell people what to do when it comes to depression. I offer these links because as lawyers and critical thinkers it is good to have a wide swath of information available, in my view.

Brian, once again I just wanted to thank you for having the courage to talk about these issues.

I don't have a lot to add substantively. I think that Bill Turnier is exactly right: there should be no stigma attached to illness, regardless whether the illness is physical, mental, or otherwise. And also, I have heard many variations on your story before from a lot of different people. This isn't meant to diminish the importance of *your* story or your bravery in telling it, but, rather, to give yet another reason that people should be able to share these stories without stigma, fear, shame, and so on.

Patrick,
I agree that there is semantic disagreement in the medical and psychological literature about whether or not clinical depression fits the dictionary definition of a "disease." The debate in this regard seems to be based on the distinction between disease vs. illness vs. disorder. The anti-disease folks note, as you do, that there is not definitive evidence of a biological cause of depression.

There is scientific evidence of biochemical and structural differences in the brains of people with depression and those without (both on brain scans and in postmortem analysis). Much of this research has focused on the prefrontal cortex of the brain and glial cells. One point of view on the disagreement on this issue (with a variety of links to studies and whatnot) can be found at http://www.psychologytoday.com/blog/in-practice/200807/where-depression-might-reside.

Similarly, NIHM refers to depression as a "serious illness," the same terminology it applies to cancer, Parkinson's and many other "diseases." See http://www.nimh.nih.gov/health/publications/depression/index.shtml#pub5. Consistent with my statement about the underlying biological issues involved with depression, NIMH states "[l]ongstanding theories about depression suggest that important neurotransmitters—chemicals that brain cells use to communicate — are out of balance in depression." But acknowledges that "it has been difficult to prove this." Id. [My understanding on this is also shaped by my doc, who is an MD and Ph.D. and a former prof. at Wake Forest's medical school, who is in a far better position to opine on this stuff than I am.]

And, of course, depression is not PURELY biological. It is a complex and multifaceted disease (or illness if you prefer). Medication is one part of the treatment. Therapy is another, equally critical part. Lifestyle changes, ditto. Effective strategies for coping with stress, likewise. I have done a great deal of all of these since my diagnosis (and continue to work on them, esp. the lifestyle changes -- exercise in particular).

At root, however, I fail to see how that semantic dispute is apropos. The critical point is that depression IS a real, diagnosable and treatable medical condition. As the CDC correctly frames the issue: "The use of medications and/or specific psychotherapeutic techniques has proven very effective in the treatment of major depression, but this disorder is still misconstrued as a sign of weakness, rather than being recognized as an illness." Op. sit. That is the critical point.

Worse, focusing on semantics risks perpetuating the stigma that is so often associated with depression and other forms of mental illness. That stigma costs people their lives. Fear of what people will think keeps people with depression suffering in silence, without effective treatment. Too many of those people take their own lives. This. Must. Stop.

Obliterating that stigma is one of the main reasons I decided to write about this topic in this very public forum, why I talk to my students about it and why I share my struggles with other lawyers and, now, total strangers.

I don't ordinarily comment on posts, but I just wanted to thank you Brian for starting this discussion, which I think is badly needed not only for lawyers, but more generally in our society. I also fully agree with you that semantic disputes about how to characterize depression are largely irrelevant (and potentially harmful) from the perspective of those who are experiencing depression -- The point is that depression is just as real and harmful for those who experience it as any other disease or condition and that it is treatable, and that point remains the same regardless of what specific term one uses to describe it. So thanks again for your willingness to put your own experience out there in such a public way and for the conversation that you've started here.

My focus was not just on “semantics” in a pejorative sense, but the meaning of concepts, which in science (in this case, psychology, psychiatry, and medicine) and philosophy is important and has real world consequences, as Michael Pardo and Dennis Patterson's Minds, Brains, and Law: The Conceptual Foundations of Law and Neuroscience (OUP, 2013) well demonstrates. Too imply my comment was therefore lacking in the requisite gravity or seriousness for broaching this topic strikes me as unfair and bereft of a basic principle of charity in conversational discourse. Your reply to my comment helpfully altered the original, and misleading if not mistaken definition of depression: “Depression is a disease caused (in very basic and general terms) by an imbalance and/or insufficiency of two neurotransmitters in the brain: serotonin and norepinephrine.” In Western biomedicine, “disease” has a specific meaning,* and misuse of the concept is not without consequences: medical, moral, political, economic, and most importantly, in the therapeutic treatment of sundry bodily and mental illnesses.

And there is a more-than-plausible argument that many instances of “depression” are not of the clinical sort that warrant psycho-pharmacological intervention and thus not deserving, either by analogy or speaking figuratively, the appellation “disease.”

I would not quibble with the proposition that, on occasion, depression is “a real, diagnosable and treatable medical condition.” In fact, I think very few people would deny the truth of that proposition. Anecdotal evidence, to be sure, but I’ve known more than a few people over the years (surprisingly?) eager to share their personal stories of depression and the fact that they’re taking this or that drug by way of battling the illness. My wife, who works in a hospital, says at least half of her co-workers appear to be taking prescriptions for anxiety or depression (there may be more, that’s just the approximate number who’ve informed others of their prescriptions), and none of them appear to be experiencing the least bit of stigma with regard to their illness (perhaps the converse is unique to the legal profession). I have several current neighbors in which this can be said as well.

Again, not all forms of depression are the same, and some forms are more akin to that which we used to call “sadness” (even if you choose to be dismissive of a book based on an extravagant inference from a subtitle before reading its contents).

I suspect I take mental illness no less seriously than you do, which might explain why I’ve spent what some might call an inordinate amount of time (given that I’m not a medical professional of any sort) reading the relevant literature in philosophy of science, the natural sciences, psychology, psychiatry, and medicine on this subject.

*See, for example, Paul Thagard’s How Scientists Explain Disease (Princeton University Press, 1999), and more relevant to our case although I’m not persuaded by his argument (if only because we understand ‘the mental’ rather differently), Dominic Murphy’s Psychiatry in the Scientific Image (MIT Press, 2006).

Brian, I just want to add to the chorus of voices thanking you for bringing up this important issue. I circulated your first post to our faculty and decided to discuss it in my seminar yesterday. The response I got from students was overwhelmingly positive, and we all had a frank discussion about it. It was an important reminder to me that preparing students for legal practice also involves preparing them for the occupational hazards of depression and anxiety. Thanks.

Let’s assume, for the purpose of argument and as noted by W. David Ball above, that law school students need to learn about the “occupational hazards of depression and anxiety.” In other words, we assume that law school does not in the first instance disproportionately attract students predisposed to or already afflicted with mental illness, and that the profession itself is unusually dangerous when it comes to risk for depression and anxiety (citing, for example, the statistics mentioned in Brian’s first post), being analogous if not similar in this way to unusually hazardous jobs generally, such as being a fisherman, logger, or aircraft pilot (to cite the top three from a list of ten such occupations compiled by the U.S. Bureau of Labor Statistics). Moreover, there are myriad other (some less serious) and related problems that have prompted widespread concern among folks in the legal profession and legal education as noted in a recent unpublished article by Lawrence S. Krieger (‘with Kennon M. Sheldon’): “emotional distress, dissatisfaction, and unethical or unprofessional behavior among practicing lawyers.”* Krieger and Sheldon also reiterate our earlier point: “There is ample literature to raise questions about lawyer and law student mental health; the legal profession, as compared to other occupations, may well harbor a disproportionate number of unhappy people.”

According to our authors,

“there has been no theory-driven empirical study investigating the experiences, attitudes, and motivations of practicing lawyers, or how those factors relate to attorney emotional health or well-being. The current study was conceived to address this void. Rather than addressing whether lawyers are happy, this study presents data pointing to who is more, and less, happy in the profession and specifically why that appears to be true. This report, then, is intended to provide practical guidance to lawyers, law students and law teachers seeking to improve their own well-being or that of others—regardless of the level of well-being or ill-being in the profession.”

The abstract provides a summary of their conclusions:

“Data from several thousand lawyers in four states show striking patterns, repeatedly indicating that common priorities on law school campuses and among lawyers are confused or misplaced. Factors typically afforded most attention and concern, those relating to prestige and money (income, law school debt, class rank, law review, and USNWR law school ranking) showed zero to small correlations with lawyer well-being. Conversely, factors marginalized in law school and seen in previous research to erode in law students (psychological needs and motivation) were the very strongest predictors of lawyer happiness and satisfaction. Lawyers were grouped by practice type and setting to further test these findings. The group with the lowest incomes and grades in law school, public service lawyers, had stronger autonomy and purpose and were happier than those in the most prestigious positions and with the highest grades and incomes. Additional measures raised concerns: subjects did not broadly agree that judge and lawyer behavior is professional, nor that the legal process reaches fair outcomes. Specific explanations and recommendations for lawyers, law teachers, and legal employers are drawn from the data, and direct implications for attorney productivity and professionalism are explained.”

And from the paper itself:

“The data contradicts beliefs that prestige, income, and other external benefits can adequately compensate a lawyer who has not secured autonomy, integrity, meaningful/close relationships, and interest and meaning in her work. The data therefore suggest fundamental changes in the belief system shared by many law students, lawyers, and their teachers and employers. In particular, the shared understanding of ‘success’ needs to be amended so that talented students and lawyers more regularly avoid self-defeating behaviors in the pursuit of success. [….]

For pre-law students, the data suggest choosing a law school for its sense of fit with their personal values and personal learning goals and styles, rather than from focusing on school prestige and USNWR rankings. Law students and lawyers would realize greater well-being from culturing their sense of self, personal purpose, and positive relationships with other people in personal and professional life, than from focusing intensely on rewards and recognition.

For teachers and employers, the findings repeatedly suggest a shift in institutional emphasis from competition, status, and tangible benefits to support, collaboration, interest, and personal purpose. The result will likely be happier, more highly functioning students and employees, and therefore more highly functioning schools and work places. The research suggest perhaps a more immediate and important responsibility for law teachers. They impact students early in the formation of professional attitudes and identities, and that impact is apparently negative for many students, particularly with regard to the kinds of internal psychological factors found here to be the primary correlates of lawyer well-being. One important strategy would be to approach the task of teaching legal analysis with humility, clearly conveying to students that, while this skill will enable them to dispassionately analyze and argue legal issues while ignoring their own instincts, values, morals, and sense of caring for others, such a skill must be narrowly confined to those analytical situations. This is not a superior way of thinking that can be employed in personal life or even to most work situations, without suffering psychological consequences.” See: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2398989

I just want to thank you as well for sharing this story. As a law student I certainly know how important it is to talk about this, and how little it is talked about.

I came into law school diagnosed with episodic MDD and perhaps I should have thought a little more about what I was getting myself into. Law school is a place that fosters self-destruction, I think. You're encouraged to skip sleep and push yourself to the limit to over-achieve and beat your classmates.

I've shared my illness (and I do think of it that way - I know another comment discussed this and I agree with you that although it may be true that depression is not always clinical, debating the point can and DOES stigmatize those who do suffer clinically into silence) with professors successfully, but I'm terrified of "coming out" in the workplace for many of the reasons you stated. I just want you to know that I truly look up to you and I hope you inspire others to be open and honest and make the legal profession a more open place to discuss mental illness.

I am an Attorney in Cincinnati Ohio. My work was featured in the January CNN story. Thank you for writing this story particularly your personal narrative. As you well know, so many people share your experiences. As the head of the Cincinnati Bar Association's Health and Well-being committee, I have heard numerous stories about how depression begins and have seen its tragic ends first hand.

I have many questions for you. First what was your Lawyers Assistance Program experience? Were you made to sign a contract? Did you find support there? Does North Carolina have specific depression related programming??

Second, our Committee is attempting to get support group formed for attorneys who have depression and or anxiety. Do you think you would have benefited from this approach? Do you think it would provide support, information and help having a group of lawyers with whom you could discuss your depression?

Finally, from the perspective of someone who has resisted falling into a hole I commend you for your candor and your willingness to make yourself available to others in response to questions.

Thank you for sharing your experience with and comments upon depression. I know that my own personal battle with serious depression has been the major battle of my life. Escaping the gravitational pull into the black hole took years and the cooperation and support from my wife, daughter, and a very skilled psychiatrist.

My advice to my colleagues is to recognize and act on the symptoms as soon as possible. And don't give up.

In North Carolina, we are fortunate to have a fantastic Lawyer Assistance Program (www.nclap.org) via the NC State Bar (the licensing authority) and a program called BarCARES (www.ncbar.org/about/barcares) via the N.C. Bar Association (the more active professional organization for lawyers). NC LAP focuses, primarily, on peer support and peer counseling, as well as referrals, interventions and the like. BarCARES, provides confidential assessments and counseling, and also sponsors CLE programs on mental health and substance abuse issues.

It was via NCLAP (in the guise of a colleague who was involved as a peer counselor), that I found my way to Louis Allen, the MDNC Federal Defender, who [truly] helped safe my life. I don't recall having to sign a contract of any sort (perhaps that would have been different if I had some pending issue with the Bar's disciplinary committee, which I did not).

Two of NCLAP's main programs are peer counseling and peer support groups. I think both can be very helpful. For me personally, I found the peer counseling aspect more helpful (I am an introvert and was, I think, too far down the hole for a group setting to be anything other than overwhelming). However, I know many lawyers who have benefited significantly from the peer support group setting -- especially in alleviating the sense of loneliness and finding folks with similar issues. For me, having access to Louis via NCLAP's peer counseling program was absolutely critical in my recovery. So, I think developing that type of network -- of both peer counselors and peer support groups -- is well worth the effort.

Lastly, NC does have a mandatory mental health/substance abuse CLE requirement (1 hour every 3 years). The NCBA's Lawyer Effectiveness and Quality of Life Committee (on which I serve) and BarCARES regularly sponsor CLE programs on these topics. I have planned one conference completely devoted to these topics (see http://gateway.ncbar.org/store/seminar/seminar.php?seminar=20346) and spoken at others. However, I am always a bit disappointed with the nature of the audience at many mental health/substance abuse seminars. They often have a "preaching to the choir" feeling to them. The people who come often have first hand experience and are very interested in the topic (but don't NEED it). Those that really need it often stay away and fulfill the requirement online (or simply read the newspaper and leave immediately, just so they can check the box). So, I have mixed emotions about the effectiveness of a standalone CLE requirement. [After the conference linked above, I joked that for the LEQLC's next conference, we should call it the "Litigation Section Annual Meeting" and then lock all the doors and talk to the attendees about mental health and substance abuse instead.] Perhaps Kentucky has the right idea with making it a mandatory part of another program.